The focus of this blog is on the wonders of government-run health-care everywhere but I also note the damage done to private medicine by a legal system that supports predatory litigation.

The long-established socialized medicine systems in Britain and Australia are a particularly relevant warning about where such systems end up.

Posts by John J. Ray (M.A.; Ph.D.)

Friday, September 30, 2005

CALIFORNIA PUBLIC MEDICINE FALLING APART

Thousands of doctors converged Tuesday on Capitol Hill calling for congressional help to keep emergency rooms open. California emergency room physicians, more than 260 of whom participated in Tuesday's mass rally, said the crisis in the state is worsening by the day, caused in large measure by the rising numbers of uninsured and skyrocketing costs of providing uncompensated service. "It's a perfect storm," said Napa physician Paul Kivela, immediate past president of the California chapter of the American College of Emergency Physicians. Kivela and others said that unless something is done to reverse the trend, California hospitals will not be able to respond to Hurricane Katrina-scale emergencies such as a major earthquake.

R. Myles Riner, an emergency room physician in upscale Mill Valley, said that even there, "we are seeing more and more uninsured and finding it harder and harder to find specialists for our patients." Jan Emerson, vice president of the California Hospital Association, concurred. "We have a huge crisis in emergency room care," she said. "Seventy hospitals have closed in the last decade, 10 in the last year," she said. Those closures also wiped out emergency room services, which is the only place the uninsured can go for basic medical treatment.

Under state law, hospitals are prohibited from hiring doctors and so must contract out for those services. But Emerson said that hospitals are finding it increasingly difficult - and expensive - to arrange for medical specialists to cover emergency rooms because of the high likelihood they will never be paid. "In some areas, emergency room specialists are demanding to be paid stipends of as much as $3,000 a night just to be on call," she said. "Hospitals are paying $600 million a year to ensure that on-call physicians are available - and still some communities are having problems finding specialists," Emerson said.

Kivela said that if a patient shows up at the emergency room with a broken jaw and has no insurance, the emergency room physician has a dreadful task of finding an oral surgeon willing to come in and take the case. "I'll have to call eight or 10 different doctors," he said. "I'll spend two hours making these calls while a bed is taken up in the emergency room while sick patients wait." Sometimes emergency rooms are so saturated with patients that ambulances are instructed not to bring any more, and the ambulance drivers have to drive around in search of an emergency room that will take the patient, the doctors said.

Often, when a patient has been seen in the emergency room and admitted to the hospital, that patient must wait for hours until a bed is found, adding to the crowding and delay for others, to say nothing of the misery level for the patient. "I saw a patient in the emergency room last week on the verge of a heart attack," Dr. John Bibb of Los Angeles said. "The hospital was full. So this person had to wait on a gurney in the emergency room, next to a patient who is throwing up and another who is screaming. It is not a place for anyone on the verge of a heart attack."

Federal law requires emergency rooms to treat and stabilize everyone with a serious illness, severe pain or who is in labor, and in California, patients can't be asked about their ability to pay until services have been provided. "It's a completely unfunded mandate," Bibb said.

The solution the doctors were advocating Tuesday would add incentives for emergency room service. It would limit their costs of malpractice insurance by providing them government-paid coverage for treating the uninsured, like Public Health Service doctors receive. It also would offer 10 percent bonuses to hospitals and doctors involved in emergency room services to Medicare recipients.

For greatest efficiency, lowest cost and maximum choice, ALL hospitals and health insurance schemes should be privately owned and run -- with government-paid vouchers for the very poor and minimal regulation. Both Australia and Sweden have large private sector health systems with government reimbursement for privately-provided services so can a purely private system with some level of government reimbursement or insurance for the poor be so hard to do?

Comments? Email me here. If there are no recent posts here, the mirror site may be more up to date. My Home Page is here or here.

Thursday, September 29, 2005

He killed a patient by incompetence but he's still working in the system. If I was a public hospital patient in Queensland I would refuse to be touched by an "overseas-trained" doctor

Another overseas-trained doctor scandal erupted at the health inquiry yesterday after allegations a Russian surgeon botched procedures and contributed to the death of a Bundaberg patient. The surgeon, Dr Anatole Kotlovsky -- now employed at the Royal Brisbane and Women's Hospital -- was singled out by a more qualified former colleague from Bundaberg who said the Russian-born medico appeared to be well out of his depth.

Dr Lakshman Jayasekera told inquiry commissioner Geoff Davies, QC, he was called in by a nurse to provide urgent help for the patient. He said he was not working when "I received a telephone call from a theatre nurse, whose name I recall only as Gail, (who) called me and asked me to come in, using the words 'Lucky, can you come in as we have a patient who is going to die on the table'." "I immediately went to the hospital and I found a patient that was in the process of being operated on by the Russian doctor and he had conducted an operation on this patient not knowing what to do."

Dr Jayasekera, an Australian-qualified surgeon and fellow of the Royal Australasian College of Surgeons, said he completed the operation successfully and complained to a superior who asked him to supervise Dr Kotlovsky in future. But he said that a few days later the Russian doctor "messed up" a second operation and had gone against advice about how to do the procedure. "He ignored my instruction and carried out the difficult operation without my supervision and caused damage to the patient, so much so that the patient was evacuated to the Gold Coast Hospital for urgent emergency treatment and I understood that that patient passed away," Dr Jayasekera said.

Dr Kotlovsky was employed at the Bundaberg Base Hospital in early 2002, a year before the arrival of rogue surgeon Dr Jayant Patel, whose negligence has since been linked to the deaths of 13 patients. Dr Kotlovsky, 48, whose curriculum vitae lists numerous qualifications from Russia before he became an Australian citizen in 1994, told The Courier-Mail yesterday he had never been made aware of the allegations.

Dr Kotlovsky described the allegations as "absolutely incredible". "I would like to know what they are talking about," he said. "It is completely incorrect. I remember all my patients at Bundaberg Base Hospital."

In evidence at the inquiry last month, Dr Kees Nydam, a member of Bundaberg hospital's management team, described the case of Dr Kotlovsky as "a bit of a disaster". Dr Nydam said he questioned if Dr Kotlovsky ever had the pediatric surgery qualifications he claimed to have achieved in Moscow. "Nursing staff, junior medical staff said 'this guy is a bit funny, we don't know exactly what'," Dr Nydam told former inquiry commissioner Tony Morris, QC. "I was particularly keen to get Lucky's co-operation in providing some degree of supervision."

A suppression order on Dr Kotlovsky's name, sought by Medical Board lawyer Ralph Devlin, was lifted late yesterday by commissioner Davies. Australian Medical Association Queensland president Dr Steve Hambleton said Dr Kotlovsky position at RBWH raised several questions about why that hospital needed to have overseas trained surgeons because it was classified as an "area of need".

For greatest efficiency, lowest cost and maximum choice, ALL hospitals and health insurance schemes should be privately owned and run -- with government-paid vouchers for the very poor and minimal regulation. Both Australia and Sweden have large private sector health systems with government reimbursement for privately-provided services so can a purely private system with some level of government reimbursement or insurance for the poor be so hard to do?

Comments? Email me here. If there are no recent posts here, the mirror site may be more up to date. My Home Page is here or here.

Wednesday, September 28, 2005

HEALTH DISASTER COVERUP GOES RIGHT TO THE TOP OF THE QUEENSLAND STATE ADMINISTRATION

Good to have those nice socialists looking after you -- as long as you like being in the mushroom club, that is (being kept in the dark and fed bull***t)

The senior public servant implicated in a high-level cover-up of hospital data has extricated himself from the saga, telling the health inquiry his [socialist] political masters were driving the agenda in a bid to protect themselves. Justin Collins, manager of the now-controversial Measured Quality department at Queensland Health, said his unit wanted to disseminate its groundbreaking review of the state's hospitals when it was compiled in mid 2002, but that process was delayed by almost a year after the health minister of the day and then members of the Premier's Department became involved. The inquiry was told Mr Collins briefed then health minister Wendy Edmond and director-general Rob Stable in August, 2002, on the intended release of the 60 individual hospital reports and an accompanying public report, but the documents were taken to Cabinet and the public report "finessed" by ministerial staffers before it was eventually released in mid 2003.

Under freedom of information legislation, documents taken to Cabinet can be kept secret unless the Government chooses to release details. The individual hospital reports were kept secret after a directive from Premier Peter Beattie and only released in restricted form to selected senior hospital administrators. Mr Beattie has argued that Queensland Health recommended the hospital reports not be released publicly.

Mr Collins, a public servant for 13 years, was embroiled in the controversy last week when the inquiry was shown a ministerial briefing he wrote which recommended a second lot of hospital data should also be taken to Cabinet to afford it "the same consideration for FOI exemption". But Mr Collins said the phrase was inserted by a superior and he instead painted himself as an unwilling participant in the whole process of reworking the documents. He said his impression was "Cabinet was very nervous about the existence of the hospital reports and who would end up seeing them".

He said he was frustrated by the delay in the dissemination of the hospital data, which crushed the effectiveness of the program, and admitted he was "embarrassed" by the excuses he was forced to give to clinicians about why they could not see the reports. Mr Collins said he told Ms Edmond and Professor Stable he was not happy with the restrictions imposed by Cabinet, but it did not make a difference.

Under cross-examination by Queensland Nurses Union barrister John Allen, Mr Collins agreed changes made by Government staffers to the public report did not enhance the value of the information to clinicians or the public.

For greatest efficiency, lowest cost and maximum choice, ALL hospitals and health insurance schemes should be privately owned and run -- with government-paid vouchers for the very poor and minimal regulation. Both Australia and Sweden have large private sector health systems with government reimbursement for privately-provided services so can a purely private system with some level of government reimbursement or insurance for the poor be so hard to do?

Comments? Email me here. If there are no recent posts here, the mirror site may be more up to date. My Home Page is here or here.

Tuesday, September 27, 2005

Flu vaccines not very effective in the elderly, researchers find

i.e. the very group that our wiseheads most target them at

Vaccines against influenza are modestly effective for elderly people in long-term care facilities, but for those living outside of such homes their effectiveness is even less, researchers have found. The study was published online on September 21 by the medical journal The Lancet.

Flu vaccines are widely recommended by doctors, the researchers noted. In 2000, 40 of the 51 developed or rapidly developing countries officially recommended vaccination for all individuals aged 60-65 or older. Nonetheless, their effectiveness doesn’t appear to be as strong as is widely assumed.

Tom Jefferson of Cochrane Vaccine Field in Rome, Italy, and colleagues identified and assessed 64 comparative studies of the effectiveness of influenza vaccines in individuals aged 65 years or older. Combining data from 15 studies, they found that in elderly individuals living in the community, vaccines based on inactivated flu viruses were not effective against influenza, but they did prevent up to 30 percent of hospitalisations for pneumonia. Combining data from twenty-nine studies, they found that in elderly people in long-term care facilities, inactivated influenza vaccines prevented up to 42 percent of deaths caused by influenza and pneumonia.

Therefore, while vaccines do have an effect, “the usefulness of vaccines in the community is modest,” the researchers wrote. “We need a more comprehensive and perhaps more effective strategy in controlling acute respiratory infections,” Jefferson said in an email. More focus should be placed on the context in which flus arise, he added, which means paying greater attention worldwide to personal hygiene and adequate food, water and sanitation.

For greatest efficiency, lowest cost and maximum choice, ALL hospitals and health insurance schemes should be privately owned and run -- with government-paid vouchers for the very poor and minimal regulation. Both Australia and Sweden have large private sector health systems with government reimbursement for privately-provided services so can a purely private system with some level of government reimbursement or insurance for the poor be so hard to do?

Comments? Email me here. If there are no recent posts here, the mirror site may be more up to date. My Home Page is here or here.

Monday, September 26, 2005

HAS THE FDA BECOME UNMANAGEABLE?

Whichever way it jumps it is going to displease someone. Time to abolish it and start a new agency devoted to ensuring reasonable drug safety only. Drug effectiveness should be something left for a different agency with advisory powers only. "First do no harm" (Hippocrates) is still hard to beat as an approach

Food and Drug Administration Commissioner Lester Crawford is out only two months after the Senate confirmed him to run the agency. President Bush designated Dr. Andrew C. von Eschenbach, the director of the National Cancer Institute, the acting replacement. Crawford's surprise resignation, submitted Friday and effective immediately, gave no specific reason for his departure. "It is time at the age of 67, to step aside," he wrote in his resignation letter.

Crawford's tenure was marked by increasing criticism of the agency by those who contended it had become more interested in politics than in its mission to protect consumers.

Earlier this year, the FDA-approved painkiller Vioxx was pulled off the market over health concerns. Thousands of heart monitors have faced recall over malfunctions. And the agency has delayed approving an emergency, morning-after contraceptive called "Plan B" for over-the-counter sales despite assurances it is safe. Some religious conservatives opposed the drug. Crawford's time at the agency included more than a year as acting commissioner during a lengthy confirmation process. He won the Senate's backing in July only after telling senators the agency would make a final decision on legalizing Plan B for over-the-counter sales by Sept. 1. Then in August word came of another delay, prompting intense criticism from proponents of Plan B and leading to the resignation of the FDA's top woman's health official.

Crawford, a veterinarian who specialized in food safety, was named acting commissioner in February 2004. Bush elevated Crawford to commissioner in part because his experience was deemed important as the FDA attempted to better safeguard the food supply against bioterrorism. In a speech last Monday in Washington, Crawford gave no sign he was planning to leave, instead discussing upcoming FDA policy on the safety of cloned beef and talking about agency plans to mark the 100th anniversary of the Food and Drugs Act of 1906. Health and Human Services Secretary Mike Leavitt accepted Crawford's resignation "with sadness," HHS spokeswoman Christina Pearson said. "We thank him for his service and wish him well," she said. Asked if he was forced to resign, Pearson declined to comment further, calling it a personnel issue.

Crawford's replacement, von Eschenbach, is a urologic surgeon. A Philadelphia native, he took over the National Cancer Institute, the government's lead agency in researching cancer treatments, in 2002. Prior to that, he served as chief academic officer of the University of Texas M.D. Anderson Cancer Center in Houston. Von Eschenbach wrote in 2004 that he has survived three cancer diagnoses: melanoma in 1989, and more recently, prostate cancer and basal cell carcinoma. In published articles, von Eschenbach has laid out an ambitious - some would say unrealistic - goal of eliminating suffering and death due to cancer by 2015, turning it into a manageable disease.

Many FDA critics lauded Crawford's departure. "The American consumer should shed no tears at Mr. Crawford's resignation," said Sen. Byron Dorgan, a North Dakota Democrat who voted against Crawford's confirmation. "The fact is, he took the side of the pharmaceutical industry and against consumers at virtually every opportunity." "In recent years, the FDA has demonstrated a too-cozy relationship with the pharmaceutical industry and an attitude of shielding rather than disclosing information," said Sen. Charles Grassley, R-Iowa, who has spent 18 months investigating the agency.

But one consumer group lamented Crawford's departure, particularly the loss of his food-safety expertise. "The agency has had so much turnover in the top spot, and turmoil throughout, that it could have benefited from a period of steady leadership," said Michael Jacobson of the Center for Science in the Public Interest.

Crawford, who had worked at FDA on four separate occasions over the last 30 years, on Friday cited among his accomplishments new steps to improve drug safety, efforts to speed drug development, and bringing more funding to the cash-strapped agency through manufacturer-paid fees.

For greatest efficiency, lowest cost and maximum choice, ALL hospitals and health insurance schemes should be privately owned and run -- with government-paid vouchers for the very poor and minimal regulation. Both Australia and Sweden have large private sector health systems with government reimbursement for privately-provided services so can a purely private system with some level of government reimbursement or insurance for the poor be so hard to do?

Comments? Email me here. If there are no recent posts here, the mirror site may be more up to date. My Home Page is here or here.

Sunday, September 25, 2005

Thoughts On Health

Just to show that this blog is not all gloom, below is a rather satirical article by Jonathan David Morris

I don’t understand commercials for medicine anymore. I mean, I understand what they’re trying to say when they advertise a medication and list its possible side effects. I just don’t understand why they bother anymore. Nobody takes these advertisements seriously. The other day, I saw a spot for something called Restless Legs Syndrome. I was stunned when it ended without turning into a “Good news; I just saved 15 percent on my car insurance by switching to Geico” commercial. That’s how bad it’s gotten. It doesn’t even matter how legitimate the affliction is. It could be cancer at this point. It could be a pill to stop spontaneous human combustion. Wouldn’t matter. I see these commercials and instinctively shrug them off. I suffer from Grain of Salt Disorder. They come on my TV and talk about some crippling disease, and all I see in my head is Victoria Jackson slamming her extra fingers under the door of a photocopier in the old SNL commercial for Toe-Riffic and Handi-Off. ("Pick you up at six?” “Make it five.” Ah, polydactyly...) Sadly, I’m not sure who this says more for: Geico or the medical industry. Some other health-related observations:

* Everyone’s got an addiction now. Food addiction. Shopping addiction. You name it, and somebody’s got it. Except me. I don’t have any addictions. I don’t even have any hobbies. I look around sometimes and I start to feel left out. You know what I want? Addiction addiction. I want to be addicted to being addicted to things. I’ll just run the gamut and rack up one new addiction after the other. Cigarettes. Beer. Stealing. Whatever you got. Eventually, I’ll become addicted to being addicted to having addictions. At that point, I’ll be unstoppable. People will point at me on the street. “Did you hear JDM’s addicted to porn now?” “I thought he was addicted to gambling?” “Yeah, turns out he just didn’t know when to quit.” “What a shame. He was so young, too.”

* The CIA should bring back leprosy. Just unleash it into some random community somewhere. Say, Council Bluffs, Iowa. No one would see it coming. I wonder how that would work out. Soon you’d start seeing separate leper water fountains. Lepers wouldn’t be allowed to play baseball, so they’d have to start a special Lepers League. Eventually, the lepers would join the ACLU and march for their rights on Washington, and Congress would agree to pay them reparations in the form of a giant Publishers Clearinghouse check. But then all the congressmen would contract leprosy when they handed the check over, and we’d be forced to establish an all-monkey contingency government while our old government went underground. Things would be different at first. It would take some getting used to. But in the end, it would turn out life was just one long Charlton Heston movie, and the world would learn an important lesson on democracy. I say go for it.

* I could live with agoraphobia.

* What drives a grown man to become a proctologist? Is that something you spend your whole life dreaming about, or is it more of a last-minute career decision? I used to think being a podiatrist was weird, but at least with podiatry you can say you have a foot fetish. You can’t really do that with proctology. Something about “I’ve always had a passion for rectums” just doesn’t sound right. How do you go about telling your father you’ve chosen this field anyway? Do you ask him to sit down? Bend over? Or what?

* In the future, human beings will probably have wireless network adapters implanted in their heads, and computer monitors installed on the insides of their eyes. Then we’ll communicate telepathically by using instant messenger. And whenever we want to know something, we’ll just think about Google.

* How come doctors never see you on time? I swear, these guys are like going to a theme park. You wait 90 minutes for a two minute ride. Why is that? What causes doctors to consistently fall behind? Are they in bed with the people who publish Popular Mechanics or something? Do they just surf the Web and refresh their email for the first hour and a half every day? Or are they just being optimistic when they tell you to be there at five for what turns out to be a 6:30 appointment? I wonder if they’d make you wait around like that if they still did house calls.

* According to all the erectile dysfunction commercials, men with four-hour erections should seek immediate medical attention. What I want to know is, at what point does someone with a four-hour erection stop and say, “God, you know what? I might be looking at a four-hour erection here”? Are guys just sitting around their bedrooms, doped up on Cialis, bragging for the first three hours and forty-five minutes? At what point do they check their watch and say, “Gee, honey, another half hour and I’m gonna start to worry a little bit”? I don’t know, maybe it’s just my lack of four-hour erection experience talking here, but I would think after the first, oh, two and a half hours or so, you could reasonably conclude there’s trouble brewing… you know, down there. In fact, I’d send up a flag 20 minutes after I’m done with the darn thing. And that’s something else that I wonder: Where do you take this sort of problem at a quarter after one in the morning? Is there a special 24-hour four-hour erection doctor somewhere? Or are you supposed to go to the emergency room? Because I’d imagine a grown man walking into the ER with an erection in the middle of the night is slightly embarrassing. Even a little bit creepy. Is that a bottle of Viagra in your pocket, or are you just happy to be here?

* What would happen if you took melatonin with a shot of double espresso? I’d like to think you’d be perfectly fine.

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For greatest efficiency, lowest cost and maximum choice, ALL hospitals and health insurance schemes should be privately owned and run -- with government-paid vouchers for the very poor and minimal regulation. Both Australia and Sweden have large private sector health systems with government reimbursement for privately-provided services so can a purely private system with some level of government reimbursement or insurance for the poor be so hard to do?

Comments? Email me here. If there are no recent posts here, the mirror site may be more up to date. My Home Page is here or here.

Saturday, September 24, 2005

HSAs Are No Solution for Medicaid

With Congress and a federal commission trying to figure out what to do about rising costs and poor quality in Medicaid, many Republican governors think they have found the answer in vouchers and health savings accounts (HSAs). They should think again. Once all the costs imposed by Medicaid are taken into account, it becomes clear these reforms will not reduce overall Medicaid costs, and could increase them.

Medicaid has ballooned from an effort to provide medical care to the poor into the most likely vehicle for a government take-over of the health care system. In 2003, there were 36 million Americans living in poverty, but 52 million on Medicaid. The states, which administer the program, have seen Medicaid become the largest item in their budgets, even larger than elementary and secondary education.

Medicaid is also notorious for providing low-quality care. Recipients have little choice of providers, and typically receive a much lower level of care from nursing homes compared to other patients. The Urban Institute has found that low-income adults who are eligible for Medicaid but have private coverage have fewer unmet medical needs than eligible adults who are enrolled in Medicaid.

A number of Republican governors believe they have struck upon a solution to both problems: improve quality by giving recipients more choices, and control costs by giving recipients a share of the savings. They propose to give Medicaid recipients a voucher to purchase a health plan of their choice and/or to deposit money into an HSA for the recipients to manage. The idea is that insurers and providers will be more responsive to customers who can shop around, and recipients will help contain costs if they can keep whatever is left over in their HSA. These approaches have an undeniable appeal to those who prefer the private sector to public programs. Thus they have attracted the support of Republican governors such as Jeb Bush (Fla.), Mark Sanford (S.C.), and Bill Owens (Colo.), as well as any number of market-oriented health policy groups.

Personally, I support HSAs and believe they should be expanded in the private sector. But that does not mean that they or vouchers are the solution to Medicaid’s problems. If we look at all the costs Medicaid imposes on society, it becomes clear that vouchers and HSAs could make Medicaid’s problems worse. The key point is that Medicaid is a welfare program. Like all welfare programs, it encourages dependence and discourages self-reliance.

Nowadays, everyone understands that a welfare check can trap people in poverty by discouraging work, saving, etc. That’s why Congress reformed welfare in 1996. Yet Medicaid provides average benefits twice as valuable as those available under that reformed federal cash assistance program – and to 10 times as many recipients. It’s no wonder that scholars have found Medicaid also increases dependence and discourages self-reliance. Which is why HSAs and vouchers spell trouble for Medicaid. Though they may improve the quality of care, they would do so at the cost of greater dependence and higher taxes. Only two-thirds of Medicaid-eligible individuals are actually enrolled at a given time. With HSAs and vouchers making Medicaid benefits more attractive, we can expect something closer to full enrollment (read: higher taxes). Once enrolled, recipients will be even less eager to give up those now-more-valuable benefits (read: more dependence).

And what happens when seriously ill Medicaid patients face gaps in coverage after they have depleted their HSAs? Given the politics of health care, it is likely that states will cover those expenses too, which would make any budgetary savings evaporate. There is a better solution, but it involves more political courage than making Medicaid benefits more attractive. There are credible indications that a sizable chunk of Medicaid enrollees do not belong there, including many who substitute Medicaid for private coverage or who feign poverty so that Medicaid will pay for their nursing home care.

Medicaid does not exist for these people. States should rededicate the program to the truly needy by disenrolling those recipients most likely to land on their feet. Ironically, that may actually increase overall coverage, as it did for non-citizen immigrants when Congress blocked them from the Medicaid rolls in 1996. Some states, led by Democratic Gov. Phil Bredesen (Tenn.), are taking this road, but they need more help. Congress could provide that help by reforming Medicaid as it reformed welfare in 1996: cap federal funding, but give states broad flexibility to target the truly needy and reduce dependence. Doing that would reduce the overall cost of Medicaid, as it did for that other type of welfare.

Obstetricians are always getting sued for big bucks and who could say what insurance cover a doctor would have on a Russian aircraft over the Atlantic?

A Russian airline delivered more than it bargained for on a flight from Moscow to Los Angeles. A woman traveling on the Aeroflot flight gave birth on the plane with the help of flight attendants. Two doctors on board refused to help, but the airline did not say why. The airline says the woman started having contractions seven hours into the 12-hour flight. And the pilot requested a landing at the nearest military airport in Canada. But he was told the runway was too short for the Boeing 767 and continued on to Los Angeles. The delivery went well and the woman was able to leave the plane on her own carrying the baby boy.

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For greatest efficiency, lowest cost and maximum choice, ALL hospitals and health insurance schemes should be privately owned and run -- with government-paid vouchers for the very poor and minimal regulation. Both Australia and Sweden have large private sector health systems with government reimbursement for privately-provided services so can a purely private system with some level of government reimbursement or insurance for the poor be so hard to do?

Comments? Email me here. If there are no recent posts here, the mirror site may be more up to date. My Home Page is here or here.

Friday, September 23, 2005

INCREDIBLE: HOW AN ENTRENCHED PUBLIC HEALTH BUREAUCRACY DEALS WITH A RISING POPULATION

In exactly the opposite way a business would: By REDUCING the medical services available -- i.e. by cutting the size of its major hospitals. Only paying to send 15,000 people a year to private hospitals ("outsourcing") keeps the system afloat at all. I guess it's privatization by stealth. But you have to wait years before the government system gives in and farms you out

"Secret State Cabinet documents tabled at the Public Hospitals Commission of Inquiry show more than 30 patients each day during June were turned away from the Royal Brisbane and Women's Hospital because of a bed shortage.

Considered to be the largest hospital in the state, almost 550 beds were cut from the RBWH when its redevelopment was completed almost two years ago. The Princess Alexandra Hospital has undergone a similar reduction from 1100 beds in 1976 to its present 745.

To "reduce the likelihood of cancellations", Queensland Health has been forced to assess patients "with some reduction in the booking of elective surgery patients that require post-operative beds", the Cabinet documents reveal. The documents presented to the inquiry show that during the Beattie Government's seven-year term, the numbers of patients awaiting the most urgent Category 1 operations have almost doubled from 1285 when the Government came into office in July 1998 to 2383 in July 2005.

The documents also outline the political sensitivity of elective surgery lists, with Queensland Health warning Cabinet "that hospitals have been required to make financial decisions on which clinical services will be compromised to ensure elective surgery targets are met". "To continue to maintain the urgent Category 1 workload, improve Category 2 waiting times, and reduce 'long waits' in the public sector, existing election commitment funding will need to be made recurrent, and Category 3 activity will need to be significantly reduced," the documents state. "It is estimated that approximately 15,000 Category 3 procedures will need to be outsourced on an annual basis which will cost in the vicinity of $88 million per year."

The number of patients needing to be outsourced are further proof that beds have been slashed from public hospitals, according to Australian Medical Association Queensland president Dr Steve Hambleton. "There is no doubt that way too many beds were cut and the planners got it wrong," Dr Hambleton said. "We now have an impossible situation with the two major tertiary referral centres in Brisbane now at peak capacity." Dr Hambleton said the Queensland Health Code of Conduct gagged employees from speaking out, and the Cabinet documents show "senior bureaucrats were gagged as well".

The office of Health Minister Stephen Robertson yesterday refused to provide any specific answers to questions, but issued a statement saying the matters were being considered "by both the Forster review and the Queensland Public Hospitals Commission of Inquiry". "We expect both the Forster review and the inquiry to make recommendations on the management of waiting lists and elective surgery. We look forward to any recommendations regarding waiting lists from both inquiries and will comment further then."

And the coverup of the problems goes right to the top of the State government:

More evidence of a political cover-up of sensitive hospital safety data has emerged to contradict denials by Premier Peter Beattie and his deputy Anna Bligh. The written evidence to the health inquiry comes as:

* Secret documents revealed more than 30 patients a day were turned away from Royal Brisbane and Women's Hospital in June because of a bed shortage.

* The State Government prepares to launch a massive recruiting drive for doctors in England.

* Details emerged of how government officers were ordered by the Premier's Department to water down critical health findings to "reflect a less negative view"....

But a synopsis of "risks and issues" of an internal report by senior bureaucrats Dr Suzanne Huxley and Dr Frank Fiumara said there had been "a failure to release the public report due to potential political sensitivity of indicator data. " The reference was included as one of 90 attachments to a statement by sacked Queensland Health chief Dr Steve Buckland.

Mr Beattie's involvement in the cover-up was revealed in a November 2002 e-mail by a Cabinet liaison officer, Brad Smith. It has also emerged that public servants within Queensland Health were ordered to rewrite sections of the report because its original version was considered too negative for public release.

A spokesman for Mr Beattie said on Monday that the report had been released "almost unchanged" in June 2003, after it was "finalised" under the supervision of the Premier's Department. But notes made by Queensland Health staff member Justin Collins, tabled in the inquiry, show the release of the report was delayed so it could be recast in a more favourable light. The notes show the report team was instructed by the Premier's Department to reword parts of the report "to reflect a less negative view on some of the indicator results".

For greatest efficiency, lowest cost and maximum choice, ALL hospitals and health insurance schemes should be privately owned and run -- with government-paid vouchers for the very poor and minimal regulation. Both Australia and Sweden have large private sector health systems with government reimbursement for privately-provided services so can a purely private system with some level of government reimbursement or insurance for the poor be so hard to do?

Comments? Email me here. If there are no recent posts here, the mirror site may be more up to date. My Home Page is here or here.

Thursday, September 22, 2005

More than 20 cancer treatments that have been licensed for use in Britain because of their significant clinical benefits are being denied to NHS patients because of bureaucratic delays. The full extent of problems affecting the availability of life-saving cancer treatments has come to light in a report seen by The Times showing that 23 different medications are awaiting appraisal. They include drugs for cancers of the breast, colon, bone marrow, lung, non-Hodgkin's lymphoma and brain tumours. Some delays are as long as three years.

The report, compiled by the charity CancerBACUP, calls for radical reform to the appraisal process to reduce the time between a treatment receiving its licence and reaching patients. The National Institute for Health and Clinical Excellence (Nice), which provides "best practice" guidance to the NHS, has admitted that recent government cuts have created serious delays with some of its assessment programmes.

The list includes drugs such as Arimidex, a medication for early stage breast cancer in post-menopausal women that has been shown to be 25 per cent more effective than the most commonly used "best practice" treatment, tamoxifen. Last week the Scottish Medicines Consortium (SMC) recommended the drug be used for patients in Scotland. A decision by Nice, which affects usage in the rest of the United Kingdom, is not expected for another 15 months.

Under the current system, once major drugs receive a licence from the Medicines and Healthcare Products Regulatory Authority (MHRA) to be used in a certain clinical setting, they are referred to Nice by the Department of Health. Nice will then carry out an appraisal which informs best practice for the NHS. Doctors can prescribe a drug once the MHRA has licensed it, but in practice it is rare to get NHS funding until Nice has made its recommendation.

Last week The Times revealed the extent of the "postcode lottery" of treatment created by the current system, taking the example of breast cancer. While some primary care trusts were found to offer all the latest treatments, others were found effectively to ration them or not offer them at all. Almost a quarter of Nice's current treatment appraisals have been held up after a government cut to its funding of 3.5 million pounds.

Joanne Rule, chief executive of CancerBACUP, said yesterday that the current system needed an overhaul to ensure patients in desperate need of potential life-saving treatment were not kept waiting. The charity is calling for the assessment of all cancer treatments within three months of a licence being granted and the fast-tracking of drugs shown to have major clinical benefits. "It is heartbreaking for the nurses on our helpline to have to tell callers that new treatments will not be available on the NHS for several years," Ms Rule said. "We have to speed up the way new cancer treatments are monitored and assessed and fast-track the ones with the most impact. Only reform of Nice will ensure these vital treatments are available to the patients who need them."

The Department of Health said that it was aware of the problems, but the axeing of one of Nice's appraisal committees had been the organisation's decision. A spokesman for Nice said last night that the organisation's board intended to meet tomorrow to discuss ways of speeding the appraisal process, and an announcement was expected by the end of the week

It was once a boast of the NHS that private care might be more convenient and give a patient more comfort, but that when someone was seriously ill there was little advantage in going private: the outcome was likely to be the same. This no longer applies. Not only is the treatment of private patients quicker, but in private practice new drugs can be prescribed to treat life-threatening cancers as soon as they have been licensed for use in Britain and passed by the European authorities.

There is no waiting for private patients as there is with NHS patients, who have to continue with superseded drugs until the results of the deliberations of Nice on their clinical efficiency and cost effectiveness have been released. Until this has been given, the budgetary authorities of local health authorities inevitably use lack of Nice guidance as an excuse for avoiding the expense.

Frequently my patients who could afford private treatment have had better drugs years before they were available to those on the NHS. The recent examples that have caused most concern to patients aware of the advances in treatment available to their richer neighbours are the aromatase inhibitors for breast cancer; Herceptin to treat some types of breast cancer; Mabthera for one type of lymphatic cancer, as well as the newer drugs for cancer of the bowel. So far as breast cancer is concerned, in a large number of patients not only are they not being prescribed the best drug, but the necessary biological tests have not been carried out by the NHS to see if the woman's cancer would benefit from the treatment, even if the money were made available by the NHS

For greatest efficiency, lowest cost and maximum choice, ALL hospitals and health insurance schemes should be privately owned and run -- with government-paid vouchers for the very poor and minimal regulation. Both Australia and Sweden have large private sector health systems with government reimbursement for privately-provided services so can a purely private system with some level of government reimbursement or insurance for the poor be so hard to do?

Comments? Email me here. If there are no recent posts here, the mirror site may be more up to date. My Home Page is here or here.

Wednesday, September 21, 2005

DEADLY BRITISH BUREAUCRACY

Brits have paid their government for their health insurance but their government won't deliver -- even when life is at stake

A nurse with breast cancer is launching a landmark case against the Health Service in her fight to receive a powerful life-saving drug. Barbara Clark, 49, will use the Human Rights Act to try to force her local health authority to prescribe the 'magic bullet' cancer drug Herceptin. Having already undergone painful surgery and a course of chemotherapy, her consultant has told her that she could be dead within months unless she takes Herceptin. It is estimated that the drug would give her an 80 per cent chance of surviving a recurrence of the disease over the next five years, compared to 30 per cent on conventional cancer chemotherapy drugs.

Herceptin is available only to women with advanced cancer and has yet to be approved for use by sufferers in the early stages of the disease. But Miss Clark, who was diagnosed with an aggressive form of cancer in February, claims that the NHS is denying her the 'right to life' -as well as the right to look after her terminally-ill adopted son Ash, aged 11. If she wins her case, it could pave the way for hundreds of similar claims and place in doubt the role of the National Institute for Clinical Excellence, the Government's drug rationing body.

Miss Clark, who is divorced, said: "I am very passionate about this and determined to take it to the High Court. I am not going to stand back and let hundreds of women die. "Under the Human Rights Act everyone has a right to life. If there is a life-saving drug out there, then I and thousands of other women should be able to have it."

Miss Clark, a children's nurse, has already put her home in Bridgwater, Somerset, on the market to help raise the œ40,000 needed for a private course of the drug, should she lose her case. She added: "This is not just about me - I am also fighting for my son who suffers from an incurable lung disease. "He deserves to have somebody around to look after him. "If I got Herceptin at the late stages and lived the maximum time possible, that would still only be up to when he turns 16. "I always thought my role in life was to look after him until the end."

Miss Clark's lawyers have now given Somerset Coast Primary Care Trust 14 days to agree to prescribe her the drug. The trust has not yet formally replied, however it has little choice but to refuse because the drug is not licensed for use in Britain for the early stages of cancer. Stephen Grosz, a partner in the London law firm Bindman's, which is bringing the action, said yesterday: "If you can prove that a drug treatment is effective and that your life is being curtailed by you not being allowed to have that drug, then you have a strong case under the human rights legislation."

Jeffrey Tobias, professor of cancer medicine at University College London, said: "Many oncologists had anticipated this situation developing over the next few months because this agent looks very impressive." In July Patricia Hewitt, the Health Secretary, personally intervened and insisted the drug was fast-tracked by NICE. It is currently conducting a review after three trials showed that it is highly effective in women diagnosed with the disease, halving the chance of the cancer returning. However approval is thought to be still 12 months away and Miss Clark believes she could be dead long before then. And even once licensed, there is no guarantee NHS trusts will pay for the expensive treatment.

The recommended course of treatment using Herceptin usually lasts for one year. Currently, those with advanced stages of breast cancer are treated on the NHS at a cost of œ19,500. But for those like Miss Clark, who are in the early stages of the disease, and who have to pay for themselves, the treatment costs about œ30,000. Dorothy Griffiths, who has set up a patients' pressure group to fight for access to Herceptin, said: "There will be a lost generation of women if this drug is not administered in time. "The reason for not giving the drug on the NHS has been one of safety. However, you can pay for the drug privately - so does paying for it make it safe? It is a ludicrous situation."

Herceptin is designed to treat the aggressive type of tumour, known as HER-2 positive, which is found in one in four of the 40,000 women diagnosed with breast cancer in the UK each year.

For greatest efficiency, lowest cost and maximum choice, ALL hospitals and health insurance schemes should be privately owned and run -- with government-paid vouchers for the very poor and minimal regulation. Both Australia and Sweden have large private sector health systems with government reimbursement for privately-provided services so can a purely private system with some level of government reimbursement or insurance for the poor be so hard to do?

Comments? Email me here. If there are no recent posts here, the mirror site may be more up to date. My Home Page is here or here.

Tuesday, September 20, 2005

HSAs Gaining Popularity, Can Be Better

Proponents of Health Savings Accounts (HSAs) predicted they would revolutionize the health marketplace. Now, less than two years after becoming law, more than a million people own HSAs. That's twice as many as in September 2004, according to a study released in May by the trade group America's Health Insurance Plans. By most accounts, HSAs are having an enormously beneficial effect on the design of health insurance in this country. Instead of an employer or insurer paying medical bills, more than one million people are managing some of their own health care dollars. Yet despite their many advantages, health economists argue HSAs can be made even better by improving incentives and creating opportunities for the chronically ill and freedom from unnecessary regulation.

Patients can exercise discretion for many of their health care needs, which is one of the things that attracts people to HSAs. Prescription drugs are a perfect example. Devon Herrick, a senior fellow with the National Center for Policy Analysis who has studied the prescription drug market extensively, says "patients can save a lot of money if they shop for drugs the way they shop for a loaf of bread." A case in point: The annual cost of brand-name drugs for arthritic pain relief is typically $800 more than for over-the-counter substitutes, and the brand-name remedies are riskier. (Vioxx and Bextra, for example, have been removed from the market.) Since drugs affect different people differently, individual patients are in the best position to determine whether the tradeoff between cost and pain relief is worthwhile.

However, HSA owners are finding not all medical services are the same. A semiconscious patient on a gurney, for example, is not in a position to make choices about alternative treatments. Even if he could, discretion in this setting is typically inappropriate. The HSA law treats all these cases the same, however. It requires a high, across-the-board deductible and requires the patient to bear the costs of purchases below the deductible amount. (See accompanying figure.) Many health economists believe a better approach would be to allow insurers to design their plans so different deductibles (and copayments) apply to different medical services. Put simply, high deductibles are best in situations where patient discretion is possible and appropriate, while low or no deductibles are better in situations where patient discretion is more difficult or inappropriate.

Another area where HSAs could be improved, health economists believe, is to provide financial incentives to the chronically ill to control costs. The chronically ill are responsible for an enormous amount of health care spending. Almost half of all health care dollars are spent on patients with one of five chronic conditions: asthma, diabetes, heart disease, hypertension, and mood disorders. Treatments for the chronically ill are usually repetitive, requiring the same procedures, visits, and/or medicines, week after week, year after year. Consequently, cost-saving discoveries by these patients are not one-time events. Rather, they pay off indefinitely and could be financially very rewarding to a patient who must pay these costs out of pocket. Numerous studies have found the chronically ill can reduce costs and improve quality by managing their own care. But health care management is difficult and time-consuming. So patients should reap health rewards and financial rewards from making better decisions. One suggestion is to allow insurers to create versatile HSAs for patients with chronic conditions, adjusting the accounts' funding to fit specific circumstances.

Overall, proponents of HSAs believe the accounts could be improved and become the dominant form of health insurance if Congress simply stepped aside and allowed the market to make many of the design decisions. As proof, they point to the experience of South Africa. HSAs (called Medical Savings Accounts) emerged in the 1990s in Nelson Mandela's South Africa. Since the government never passed a law dictating an HSA design, the plans developed in a relatively free market. Today, HSAs have captured more than half the market for private health insurance there. "Not only have MSA plans proved popular, they have also developed in ways that are better designed to meet customer needs than in the U.S.," notes Shaun Matisonn, executive vice president at Discovery Health, a South African insurance company.

In the United States, however, Congress has capped HSA contributions and required that HSAs be linked to high-deductible plans. HSAs could flourish if Congress would allow unlimited contributions to HSAs and permit such accounts to wrap around third-party insurance--paying for any expense the insurance plan does not pay.

For greatest efficiency, lowest cost and maximum choice, ALL hospitals and health insurance schemes should be privately owned and run -- with government-paid vouchers for the very poor and minimal regulation. Both Australia and Sweden have large private sector health systems with government reimbursement for privately-provided services so can a purely private system with some level of government reimbursement or insurance for the poor be so hard to do?

Comments? Email me here. If there are no recent posts here, the mirror site may be more up to date. My Home Page is here or here.

Monday, September 19, 2005

ISN'T IT WONDERFUL TO HAVE REGULATORS PROTECTING YOU?

At least the only real protection -- information -- is slowly being made more available

Psychiatrists and psychologists who have been struck off for sexual and other serious misconduct are still treating patients in NSW because of a legal loophole. A Herald investigation has found that therapists who have had sex with patients, lied in court or revealed patient secrets are able to treat patients simply by changing their title to counsellor or psychotherapist. As the law stands in NSW, anyone can call themselves a counsellor, psychotherapist, life coach, psychoanalyst or family therapist.

Compounding the problem is the fact that struck-off psychiatrists and psychologists are not obliged to reveal their history to patients, and if they do misbehave again, the Health Care Complaints Commission has no power to discipline them. Seven years ago the State Government conducted a parliamentary inquiry into unregulated health practitioners and one of proposals made was the regulation of such therapists. Merrilyn Walton, who headed the HCCC at the time, wanted to stop struck-off practitioners from setting up as counsellors but was ignored.

Now, as a result of the Herald's investigation, the Psychologists Registration Board plans to reveal names of struck-off psychologists on their website and when asked by patients. In addition the NSW Medical Board has independently decided to list disciplinary cases on its website - the first time this information has been readily accessible in NSW. Among the struck-off practitioners uncovered by the Herald:

* Shunyam Peinecke, a former psychologist struck off last year who offers counselling near Byron Bay. A tribunal found he had lied in a murder trial and deliberately destroyed patient records.

* Tony Aguado, a psychiatrist who was struck off for having sex with a patient and prescribing himself Viagra under a false name, now advertises his services as a trauma counsellor. He lists an address in Toronto, on Lake Macquarie, the same place where he abused his patient.

* Winifred Childs, a psychiatrist struck off for sexual misconduct 15 years ago, still works as a psychotherapist in Glebe. Since being struck off she became entangled in a case against another psychiatrist. The Medical Tribunal in 2001 accepted the evidence of a patient who said Ms Childs had advised her to keep her sexual relationship with her psychiatrist secret in order to protect him. Ms Childs says she was unaware of the proceedings and that the patient's evidence was untested and uncorroborated and that she had been denied justice.

Dr Louise Newman, head of the NSW Institute of Psychiatry, said regulators were failing to meet their duty to protect the public. "It's a systemic failure." Professor Walton, now associate professor of ethical practice at Sydney University, said the situation was ridiculous. "If they're struck off because they're dangerous, well how come they can still do the same thing? And they're not dangerous anymore?" Dr Newman said the danger of allowing anyone to become a counsellor was that people risked treatment from unqualified practitioners.

The NSW Health Minister, John Hatzistergos, said Victoria was conducting research into the regulation of psychotherapy and counselling and that "NSW Health will examine the results … to consider the implications." He said he would ask the HCCC, NSW Health and the Complementary Health Practitioners advisory committee to look at whether changes were needed.

For greatest efficiency, lowest cost and maximum choice, ALL hospitals and health insurance schemes should be privately owned and run -- with government-paid vouchers for the very poor and minimal regulation. Both Australia and Sweden have large private sector health systems with government reimbursement for privately-provided services so can a purely private system with some level of government reimbursement or insurance for the poor be so hard to do?

Comments? Email me here. If there are no recent posts here, the mirror site may be more up to date. My Home Page is here or here.

Sunday, September 18, 2005

ANOTHER HORROR HOSPITAL

The official inquiry into Queensland public hospitals started with Bundaberg hospital but Hervey Bay hospital also has now been revealed as having been run with great negligence. And once again it's the bureaucrats who are most at fault

Two Hervey Bay doctors whose orthopaedic surgery abilities were criticised in a Queensland Health report were victims of grossly inadequate supervision, two former colleagues said yesterday. Senior operating theatre nurse Dale Erwin-Jones told the health inquiry that Damodaran Krishna and Dinesh Sharma, Fijian-trained doctors employed as senior medical officers, were regularly rostered for duty when there was no one in the district available to supervise them. They were at one stage on call every second night, creating a potentially unsafe situation for both them and their patients.

Ms Erwin-Jones said the doctors' direct superior Morgan Naidoo was on leave two to three months every year and frequently uncontactable, while orthopaedic visiting medical officer Sean Mullen was only rostered on for a limited amount of time. She said Dr Krishna in particular tried to operate within his abilities and always attempted to get help if he ran into difficulties mid-surgery but she claimed assistance from Dr Naidoo was rare. On at least two occasions when Dr Naidoo could be contacted by phone from the operating theatre for advice, Dr Krishna "was clearly being advised 'You'll have to get on with it"', she said.

A review into problems in the hospital's orthopaedic department, commissioned by Queensland Health and conducted by the Australian Orthopaedic Association in 2004/05 found the treatment orthopaedic patients received in the region was unsafe. It led to a shutdown of orthopaedic services at the Hervey Bay hospital in May. Dr Naidoo's inadequate supervision of doctors Sharma and Krishna and his long periods of leave were singled out for criticism. One of the report's authors John North told the health inquiry on Tuesday that he did not observe doctors Sharma and Krishna operate but based his findings on staff interviews and patient files.....

Medical Board of Queensland barrister Ralph Devlin said delaying the cross-examination was only fair to doctors Krishna and Sharma "who in other material appear to be described as very good at what they did".

When he took the witness stand yesterday Dr Mullen stressed that the two doctors were not the ones to blame for problems as they were the victims of "administration failure". He said in the case of Dr Sharma he was confident he would become a good orthopaedic surgeon. He said he had for years been trying to raise the issue of the lack of supervision for the junior doctors and eventually took his complaints to the AOA because of the inadequate response from hospital management. He said on one occasion he volunteered to take a greater role in supervising the doctors, free of charge, but the offer was rejected.

And here's more that does not seem to be online but which was reported on p. 2 of the Brisbane "Courier Mail" on Sept 16, 2005. This patient was lucky. She only had her arm amputated. Others have lost their lives

"An elderly woman had to have her arm amputated in 2000 because her doctor was unavailable for six days, it was alleged yesterday.

Another surgeon, Sean Mullen, who worked occasional shifts at Hervey Bay Hospital told the health inquiry that he was contacted by a concerned nurse who was distressed about the large wound on the woman's arm and asked him to intervene. He said junior medical staff had been trying to contact the woman's doctor - the hospital's orthopaedic director Morgan Naidoo - over six days but he was unable to check on the woman.

Dr Mullen said when he saw the patient it was obvious she needed urgent surgery. He rang Dr Naidoo who asked him to take over the woman's care. Dr Mullen immediately operated and had to remove a large amount of the arm muscle because it was "dead and infected". He said the arm must have been in such a state for several days. It was subsequently amputated. "The delay ... would have led to the outcome which was amputation." Dr Mullen said.

The inquiry has heard Dr Naidoo was notoriously difficult to contact and lived in Brisbane on weekends. Because he frequently cancelled procedures, theatre staff allegedly referred to his surgical speciality as cancelectomy".

An internal Queensland Health report savaged Dr Naidoo's management of the orthopaedic department and said his absences were "of concern to both theatre and ward staff". It was reported that he was extraordinarily difficult to contact, being either out of range or out of town and that he simply did not respond to messages left by staff," the report said. "It was suggested ... when difficult issues arose, Dr Naidoo would take recreation or study leave."

Dr Naidoo has not been called to give evidence.

***************************

For greatest efficiency, lowest cost and maximum choice, ALL hospitals and health insurance schemes should be privately owned and run -- with government-paid vouchers for the very poor and minimal regulation. Both Australia and Sweden have large private sector health systems with government reimbursement for privately-provided services so can a purely private system with some level of government reimbursement or insurance for the poor be so hard to do?

Comments? Email me here. If there are no recent posts here, the mirror site may be more up to date. My Home Page is here or here.

Saturday, September 17, 2005

FDA AS THE ENEMY OF RESEARCH

"The fault, dear Brutus, is not in our stars, but in ourselves," wrote Shakespeare. It's the sort of frank self-assessment not popular with bureaucrats.

The latest example is a just-published joint report by the Food and Drug Administration and the Association of American Medical Colleges (AAMC) seeking remedies for the following: "Support for basic science in the United States has been demonstrated by the recent 5-year doubling of the NIH budget. The biopharmaceutical industry continues to increase funding for the science of drug and medical product discovery and for commercialization. In spite of this considerable investment, the number of innovative drugs and biologicals (so-called New Molecular Entities) approved by the FDA, which rose steadily during the early 1990s, appears to have peaked in 1996 and has since declined."

That's only part of a most alarming story. Drug research-and-development costs have skyrocketed, with direct and indirect expenses now exceeding $800 million to bring an average drug to market. Fewer than 1 in 3 drugs approved for marketing recoup their development costs.

Why do we find ourselves -- and more important, patients who need innovative new drugs -- in this situation? Well, the FDA constantly raises the bar for initiation and progress of new drug clinical testing. For example, in just the last few years FDA officials have arbitrarily and unexpectedly directed clinical investigators to begin trials at inappropriately low dosages; limited approval of Phase 1 studies to single-dose, instead of dose-ranging, studies; demanded unnecessary, invasive procedures on patients; and even required completion of foreign trials and results submitted before the U.S. trials begin.

The FDA's constant raising of the bar for approval, tendency to overreact and anxiety about new technologies has made the U.S. drug development process the world's longest, and it has grown longer over time. According to the Tufts University Center for the Study of Drug Development, since the 1960s total time required for drug development -- from lab synthesis or discovery to delivery to the patient -- has nearly doubled, from 8.1 to 15.2 years. Clinical testing, the part of development the FDA most intensely scrutinizes, averages eight years in the U.S., or about a third longer than in Europe.

But FDA -- and its partner in producing the recent report, AAMC (whose senior vice president, David Korn, is one of the two authors and happens to be married to a former FDA deputy commissioner) -- are blind to all this, somehow managing not to see the 800-pound gorilla at the dining room table.

Instead, they offer suggestions that, while not bad, certainly will not address FDA's manifest shortcomings. Their proposals include: Develop mechanisms to learn from failures at various drug development stages, including clinical trials and drug targeting; industry-FDA collaborations to share toxicology data; construct models for biomarker validation; propose new congressionally enacted regulatory incentive policies for small-market drugs; develop ways to share information now restricted as intellectual property or proprietary, to increase shared knowledge; and stimulate industry-government collaborative research and development.

We need changes that will fix the current system's fundamental and systematic flaws. Aggressive reform must redress the asymmetry of outcomes from the two types of mistakes regulators can make. A regulator can err by permitting something bad to happen (approving a harmful product) or by preventing something good (not approving a beneficial product). Both outcomes are bad for the public, but the consequences for the regulator are very different.

The first kind of error is very visible, bringing attacks on the regulators from the media and patient groups and congressional investigations. (All this has happened in recent months.) But the second kind of error -- keeping a potentially important product out of consumers' hands -- usually is a nonevent, eliciting little attention, let alone outrage.

Former FDA Commissioner Alexander Schmidt summarized the conundrum: "In all our FDA history, we are unable to find a single instance where a congressional committee investigated the failure of FDA to approve a new drug. But the times when hearings have been held to criticize our approval of a new drug have been so frequent that we have not been able to count them. The message to FDA staff could not be clearer."

As a result, regulators make decisions defensively -- to avoid approvals of harmful products at any cost. So they tend to delay or reject all sorts of new products, from fat substitutes to vaccines and painkillers. That's bad for public health and for consumers' freedom to choose.

We need sweeping FDA reform. First, we need to insulate policymaking and individual product decisions from politics as far as possible. Second, we need to make regulators' decisions more scientific and evidence-based. Third, we need to improve pharmacovigilance -- the monitoring of the safety of already marketed drugs -- by enhancing regulators' access to more and better data. Finally, and most important, we need to redress the culture of excessive risk-aversion and defensiveness that pervades FDA.

For greatest efficiency, lowest cost and maximum choice, ALL hospitals and health insurance schemes should be privately owned and run -- with government-paid vouchers for the very poor and minimal regulation. Both Australia and Sweden have large private sector health systems with government reimbursement for privately-provided services so can a purely private system with some level of government reimbursement or insurance for the poor be so hard to do?

Comments? Email me here. If there are no recent posts here, the mirror site may be more up to date. My Home Page is here or here.

Friday, September 16, 2005

ANOTHER AMAZING STORY FROM BUREAUCRATIZED BRITAIN

I took a close relative to see a consultant surgeon in Hampshire yesterday. I raised the subject of the NHS and with no prompting the consultant said that the NHS was in a terrible state and would go. He said that last weekend, he (and presumably his juniors) he had twelve people with fractures in an NHS hospital - in other words these patients had broken bones.

But while he wanted - as any humane person would - to operate on these twelve emergencies as quickly as possible, the hospital was still bringing him elective cases ('elective' means non-emergency cases suh as hip replacements). In describing this ghastly scene, he added that there were not even ward clerks to take notes.

It is horrible to think that you, me or one of our loved ones might break a bone and be sent - as we automatically would be - to an NHS hospital only to be left lying in bed for days of end with this broken bone. We would be in great pain, on strong pain killers that made us drowsy and there would probably be complications such as bed sores. That is not so much a health service as a torture service. The idea that non-emergency operations should take precedence is a sign that morality and decency have left the building. It is sick.

What is new is the way that an NHS doctor such as him is so passionately and openly critical of the NHS. Ten years ago, virtually every doctor or nurse I met was a committed supporter of the NHS. Now, increasingly, doctors I meet are sceptical about the NHS or downright hostile. This man was the most forthright of all and said that the NHS would have to go and it would go. It would be replaced by private sector supply, social insurance and pro bono work.

He said that he and his colleagues would be happy to spend time each week working for free for those people without funds.

For greatest efficiency, lowest cost and maximum choice, ALL hospitals and health insurance schemes should be privately owned and run -- with government-paid vouchers for the very poor and minimal regulation. Both Australia and Sweden have large private sector health systems with government reimbursement for privately-provided services so can a purely private system with some level of government reimbursement or insurance for the poor be so hard to do?

Comments? Email me here. If there are no recent posts here, the mirror site may be more up to date. My Home Page is here or here.

Thursday, September 15, 2005

WHY DOES THIS INSANITY CONTINUE?

The long work weeks of doctors in training leave them so fatigued that their reaction times are comparable to someone who is slightly drunk, researchers said on Tuesday. Resident doctors following a "heavy call" schedule that can require a 90-hour work week performed more poorly on a driving simulation test than those on a "light call" rotation averaging 44 hours a week who then drank liquor until their blood alcohol level reached 0.05 percent, the study said. Drivers with a 0.08 percent blood alcohol level are considered drunk.

The research echoes a previous study that found interns who worked heavy schedules made 50 percent more mistakes with patients and had 22 percent more serious errors on critical care units.

A survey of resident doctors also found that they were three times more likely than average to have been involved in a motor vehicle crash.

New rules enacted in 2003 lowered the weekly work schedules for U.S. doctors-in-training to a maximum of 80 hours, the report said. "Residents must be aware of post-call performance impairment and the potential risk to personal and patient safety," study author Todd Arnedt of the University of Michigan, Ann Arbor, wrote in this week's issue of the Journal of the American Medical Association. "Because sleepy residents may have limited ability to recognize the degree to which they are impaired, residency programs should consider these risks when designing work schedules and develop risk management strategies for residents, such as considering alternative call schedules or providing post-call napping quarters," he wrote.

Patients at Hervey Bay Hospital were in "very unsafe hands" because of three overseas-trained orthopaedic surgeons, Queensland's medical malpractice inquiry has been told. In the first day of evidence to the restarted Queensland Public Hospitals Commission of Inquiry, the focus switched from Bundaberg to Hervey Bay hospital. The inquiry had previously focused largely on the employment of Dr Jayant Patel as director of surgery at Bundaberg Hospital where he has been implicated in the deaths of at least 80 patients. But retired judge Geoff Davies, who was appointed to replace Tony Morris as head of the inquiry, made it clear today its terms of reference were not only confined to Bundaberg when it came to medical conditions in Queensland hospitals.

He called on evidence today from Dr John North, who co-authored a report into orthopaedic services at Hervey Bay Hospital earlier this year. Dr North said in a submission that conditions at the hospital orthopaedic unit were third world. He said the conduct of Hervey Bay Hospital's Director of Orthopaedic's Dr Morgan Naidoo and Senior medical officers in Orthopaedics Dr Damodaran Krishna and Dinesh Sharma had put patients at risk. Dr North said there were shortcomings in the trio's clinical assessment, basic communications with staff and patients and surgical skills. "A summary of the cases noted confirm the investigators knew that the people of the Fraser Coast are in very unsafe hands from the point of view of doctors Naidoo, Sharma and Krishna," Dr North said in his report. "It appears that there is a third world culture with respect to patient care at Hervey Bay Hospital simply as a consequence of the training of those employed there. "Under the circumstances prevailing at this hospital patient's safety is at severe risk."

Earlier this month the Supreme Court found Mr Morris was biased and the inquiry was effectively shut down, but resumed last week with Mr Davies in charge. Dr North told the inquiry that South African trained Dr Naidoo, and the Fijian trained Dr Krishna and Dr Sharma should have significant limitations placed on them. He recommended Queensland Health take steps to ensure all orthopaedic surgical health care activity in the public sector at the Fraser Coast cease and patients be transferred to a larger hospital where their orthopaedic care be monitored.

For greatest efficiency, lowest cost and maximum choice, ALL hospitals and health insurance schemes should be privately owned and run -- with government-paid vouchers for the very poor and minimal regulation. Both Australia and Sweden have large private sector health systems with government reimbursement for privately-provided services so can a purely private system with some level of government reimbursement or insurance for the poor be so hard to do?

Comments? Email me here. If there are no recent posts here, the mirror site may be more up to date. My Home Page is here or here.

Wednesday, September 14, 2005

MEDICAL NEGLIGENCE ABOUT A DOWN'S SYNDROME PREGNANCY IN AN AUSTRALIAN PUBLIC HOSPITAL

There is a story of great love and Christian faith here about a couple who had a pregnancy with a Down's syndrome child which they refused to abort. After various scans had been done in utero, great pressure was put on them to abort, including an incompetent diagnosis that the condition was complcated by microcephaly. The couple held fast to their faith and are now delighted with their perfectly healthy little Down's syndrome girl. With modern methods of care, Down's syndrome children can of course reach near-average levels on intelligence and are generally very good natured. Below is just one small excerpt from the story:

"Into our tale now lumbers Dr Hunt, Neurologist, a gentleman who somehow managed to be aloof and oafish at the same time.

Mrs Y's expanding abdomen had for a second time undergone an MRI scan, and we went back to the Royal Children's Hospital to see Dr Hunt and discuss it with him. It didn't start off well. We were greeted with a remark something like, `who are you and what do you want'. He hadn't discussed our situation with Miss Maixner, or even looked at the previous MRI scan. He hadn't read the file. He hadn't even read our names.

The scan results were there. He looked at them while we looked over his shoulder. He read the summary of the previous results, and promptly declared that the condition was unimproved. In other words, get the flower bed ready, your vegetable is coming.

I'm still angry about this unspectacular piece of doctoring. We looked at the scan together, and I think he just came to the easiest and laziest conclusion. Needless to say, I have no medical training - being a mere man and not one of society's lofty demigods - but unlike Dr Hunt I had actually carefully scrutinised the first MRI scan. It was obvious at a glance that this scan was very different. The cavity was much smaller, and the brain area much bigger.

He ought to have been in less of a hurry to stomp out our unrealistic false hopes, and should instead have stomped down the corridor to his colleague's office. That would be the minimum you'd expect from a medical professional wouldn't it?

After all, for all he knew, a child's life may have depended on it....."

HAVING A NORMAL BABY IN AN AUSTRALIAN PUBLIC HOSPITAL CAN BE "CHALLENGING" TOO

This from Australia's largest State -- New South Wales -- and refers to an outer suburb of Sydney

Just last month, the Health Minister, John Hatzistergos, and the Premier, Morris Iemma, had a tour of the new 36-bed maternity unit at the beleaguered Campbelltown Hospital. It was a happy occasion billed as "their first official visit together". "Every year more than 2000 babies are born at Campbelltown Hospital," Mr Iemma said during the visit, less than six weeks before this Saturday's byelection in the Macquarie Fields electorate, which the hospital serves. "This new, enlarged unit is designed to cater for the population growth in the local community." The $3.26 million redevelopment featured "six single and 15 two-bedroom maternity suites, all with ensuites," an August 10 statement said.

Eight of those 36 beds are now closed indefinitely as continuing plumbing and building problems mean they are unsafe for new mothers. In some rooms there is no running water or no hot water. In others the toilet does not flush. In one brand new room there is a large, discoloured hole in the ceiling caused by a leak from the floor above. Dr Mary Prendergast, a visiting obstetrician and gynaecologist at the hospital, said the conditions were unacceptable for patients and staff. She said it was particularly astounding "to see this in a hospital where you've just had an inquiry into your level of care". Dr Prendergast said the room closures, combined with staff shortages, were compromising women's care.

At times of high demand, women who gave birth in the delivery suites could not be accommodated on the ward and stayed in the delivery room for prolonged periods. In turn, that could mean women in the early stages of labour might be advised to wait longer at home instead of being admitted.

Marion Downey, a spokeswoman for Sydney South West Area Health Service, which administers the hospital, said: "Minor building problems in the area are being addressed and beds are gradually being opened as demands for service increases.".....

The room where on-call doctors sleep has a large hole in a wall above the bed, a roughly stripped floor with loose patches of carpet and no bathroom facilities. "The area where this accommodation is sited is being refurbished in the next month," Ms Downey said. Mr Hatzistergos confirmed that maternity services had continued while the $3.26 million redevelopment of the women's and babies unit at Campbelltown Hospital was taking place.....

Campbelltown and the associated Camden hospitals have been investigated by the Health Care Complaints Commission after staff nurses alleged there had been numerous incidents of negligent patient care. Five doctors are facing suspension or deregistration as a result of those investigations.

For greatest efficiency, lowest cost and maximum choice, ALL hospitals and health insurance schemes should be privately owned and run -- with government-paid vouchers for the very poor and minimal regulation. Both Australia and Sweden have large private sector health systems with government reimbursement for privately-provided services so can a purely private system with some level of government reimbursement or insurance for the poor be so hard to do?

Comments? Email me here. If there are no recent posts here, the mirror site may be more up to date. My Home Page is here or here.

Tuesday, September 13, 2005

ANOTHER CASE FOR TOTALLY PRIVATIZED MEDICINE

From Britain, of course. Note that the Dept. of Health says that the couple COULD have been accomodated if the hospital authorities had wanted to. Because of their high-handed decision not to, the lady had to pay again for care she had already paid for once via contributions to the government system. No prizes for guessing that the hospital did not want someone else around who might witness their sloppy procedures and demand better

A nervous mother-to-be paid £10,000 to give birth privately because an NHS hospital would not let her husband stay with her overnight. Ann Quayle says a midwife told her his presence could offend Muslim women on the ward. She and her husband Paul Kellers could afford the private treatment only by taking out a credit card loan. But 44-year-old Miss Quayle, who has had two miscarriages, said she would have been too upset and scared without him at her side. She said: "I accept that religion and culture should be catered for but so should my needs. If we're supposed to be a multicultural society, we don't need people spouting this kind of nonsense."

The Royal Free Hospital, in North-west London, categorically denied, however, that Mr Kellers had been refused permission to stay because of offending Muslim women. It said in a statement: "We cannot accommodate partners because women receiving ante-natal care are in fourbedded bays, like other patients. As soon as labour starts the woman and her birth partner can be together on the labour ward. "We don't know whether anyone made any comments about the religious or cultural needs of other patients but certainly that would not be an appropriate comment. It was not the reason that Miss Quayle's husband could not stay the night."

Miss Quayle, from nearby West Hampstead, was a week overdue when she attended the hospital's Aldrich Blake maternity day unit. Staff booked her in to be induced a week later but the refusal to let her husband join her left her in tears. Instead, the couple went to the Portland Hospital where Victoria Beckham and the Duchess of York had their children. "It makes me go hot and cold thinking about the amount of money we spent," Miss Quayle said last night as she cradled her week-old daughter Tiger Lilly. "Before she was born I would lie awake worrying about the huge expense but it's worth every penny now we have our beautiful daughter. The staff at the private hospital were wonderful but the most important thing about it all was that Paul could stay with me, sleeping on a bed by my side."

Miss Quayle, who has just started an estate agency with her husband, added: "I was disappointed to have to go private. "I pay my taxes and I feel I have paid to have my baby on the NHS. I am a huge supporter of the NHS. My mother is an NHS nurse. "My axe to grind is that my husband staying with me would not have cost a penny."

Miss Quayle said she and her 33-year-old husband had Christian, Jewish and Muslim readings when they married on July 11, four days after the London bombings. She added: "I was in hospital on the day of the bombings and a young Muslim couple were there having a baby. Because of the bombings, people's attitude towards them became hostile and I felt so sorry for them. "It shouldn't matter what religion you are. "In the politically dangerous climate we're in at the moment, you don't need people saying things like they said to me."

The Department of Health said last night it was up to individual NHS Trusts to decide whether partners could stay overnight in such cases. There is no nationwide policy on the issue.

For greatest efficiency, lowest cost and maximum choice, ALL hospitals and health insurance schemes should be privately owned and run -- with government-paid vouchers for the very poor and minimal regulation. Both Australia and Sweden have large private sector health systems with government reimbursement for privately-provided services so can a purely private system with some level of government reimbursement or insurance for the poor be so hard to do?

Comments? Email me here. If there are no recent posts here, the mirror site may be more up to date. My Home Page is here or here.

Monday, September 12, 2005

THIS IS THE SORT OF THING YOU CAN EXPECT UNDER "SINGLE-PAYER" HEALTH CARE

And cataract removal is one of the more simple and basic procedures

An age pensioner has been told he may have to wait 10 years for a cataract operation from Queensland Health. Geoff Cass, 73, of Tewantin on the Sunshine Coast, has almost lost sight in his right eye and has a worsening problem with his left. He said he would be blind, or possibly dead, before a doctor could get to him. He was on an unofficial patient list waiting for assessment to get on the official waiting list.

Mr Cass was told by a private ophthalmologist, who would likely perform the operation for Queensland Health, it could take 10 years or more. "It's an absolute bloody disgrace," he said. Mr Cass is one of thousands of Queenslanders waiting for cataract removals and other eye operations. There was an acknowledged serious shortage of full-time eye surgeons employed by Queensland Health, with visiting medical officers contracted to perform the delicate work. The Royal Australian and New Zealand College of Ophthalmologists has criticised Queensland Health for not providing adequate facilities to entice private doctors.

Mr Cass, well known in Tewantin for his volunteer work, said he could not afford $6000 to have the cataracts removed privately. Mr Cass said his wife Margaret, 72, also needed cataract surgery.

Opposition Leader Lawrence Springborg slammed the surgery delay. "It is a disgusting situation that a couple who have worked their entire lives and paid their taxes now face the prospect of spending most of their final days in darkness through no fault of their own," he said. A Queensland Health spokesman said the Sunshine Coast Health Service was not aware of any patient who had been told they must wait 10 years for cataract surgery, but he conceded the service was under pressure.

For greatest efficiency, lowest cost and maximum choice, ALL hospitals and health insurance schemes should be privately owned and run -- with government-paid vouchers for the very poor and minimal regulation. Both Australia and Sweden have large private sector health systems with government reimbursement for privately-provided services so can a purely private system with some level of government reimbursement or insurance for the poor be so hard to do?

Comments? Email me here. If there are no recent posts here, the mirror site may be more up to date. My Home Page is here or here.

Background

Postings from Brisbane, Australia by John Ray (M.A.; Ph.D.) -- former member of the Australia-Soviet Friendship Society, former anarcho-capitalist and former member of the British Conservative party.

This blog gives a lot of attention to events in Australia and Britain -- places where there already exist systems similar to the one most likely to befall the USA if the Democrats get their way -- "Free" medical care supposedly available to all through government hospitals but with a competing private sector as well. The Canadian system is considered too Soviet to provide a likely model for the USA

TERMINOLOGY: Many of my posts concern the very instructive state of socialized medicine in Australia. Like the USA, Germany and India, Australia has a system of State governments which have substantial independence from the central (Federal) government and it is they who are mainly responsible for "free" health services. It may therefore be useful to some for me to note the standard abbreviations for the States concerned: QLD (Queensland), NSW (New South Wales), WA (Western Australia), VIC (Victoria), TAS (Tasmania), SA (South Australia).

For greatest efficiency, lowest cost and maximum choice, ALL hospitals and health insurance schemes should be privately owned and run -- with government-paid vouchers for the very poor and minimal regulation. Both Australia and Sweden have large private sector health systems with government reimbursement for privately-provided services so can a purely private system with some level of government reimbursement or insurance for the poor be so hard to do?

Conservatives do NOT object to helping the poor. Government welfare legislation in aid of the poor was in fact first introduced by conservatives -- Bismarck and Disraeli in the 19th century. What conservatives want is for the help to be delivered in a sane manner. And anyone who thinks that government bureaucracies can run hospitals well is completely out of touch with reality.

One of the oldest "free" public hospital systems in the world is that in the Australian State where I live: Queensland. It dates from 1944 (Britain's NHS began in 1948). So its advanced state of decay reveals well where the slow cancer of bureaucracy ends up. It now has three "administrative" employees for every medical employee. All those clerks are really good at curing people, I guess! Frequent bulletins on the flailing but ineffectual attempts to "fix" the system will appear here -- as well as bulletins on the dreadful things it does to patients and the long waits they endure.

On all my blogs, I express my view of what is important primarily by the readings that I select for posting. I do however on occasions add personal comments in italicized form at the beginning of an article.

I am rather pleased to report that I am a lifelong conservative. Out of intellectual curiosity, I did in my youth join organizations from right across the political spectrum so I am certainly not closed-minded and am very familiar with the full spectrum of political thinking. Nonetheless, I did not have to undergo the lurch from Left to Right that so many people undergo. At age 13 I used my pocket-money to subscribe to the "Reader's Digest" -- the main conservative organ available in small town Australia of the 1950s. I have learnt much since but am pleased and amused to note that history has since confirmed most of what I thought at that early age.

I imagine that the the RD is still sending mailouts to my 1950s address!

NOTE: The archives provided by blogspot below are rather inconvenient. They break each month up into small bits. If you want to scan whole months at a time, the backup archives will suit better. See here or here